Case Report

Maxillary Canine—First Premolar Transposition

Restoring Normal Tooth Order With Segmented Mechanics

Leopoldino Capelozza Filhoa; Mauricio de Almeida Cardosob; Tien Li Anc;

Francisco Antonio Bertozd

Abstract: Tooth transpositions present at a relatively low incidence in the world population
and primarily affect maxillary canines and premolars. Treatment of this disturbance should take
into account aspects such as facial pattern, age, malocclusion, tooth-size discrepancy, stage of
eruption, and magnitude of the transposition. Mechanics for correction should be entirely indi-
vidualized, reducing the risks and adverse effects. Practitioners often select simpler options,
indicating extraction of permanent teeth, which is an irreversible procedure that may bring about
damages to the patient. This study presents a case report and treatment of unilateral transpo-
sition of maxillary canine and premolar with repositioning of affected teeth to their respective
normal positions.

Key Words: Transposition; Corrective orthodontics; Segmented mechanics

INTRODUCTION has been reported by Peck et al5 as a dental anomaly

characterized by the exchange of position between
Tooth transposition is an alteration initially reported
two adjacent teeth, especially in relation to their roots,
in the 19th century,1 and its terminology has been
or development and eruption of a tooth in a position
changing. Some publications have classified different
normally occupied by a nonadjacent tooth.
degrees of ectopic eruption as pseudotranspositions
Tooth transposition is usually associated with other
or incomplete, partial, simple, or coronal transposi-
dental anomalies in the same patient, such as hypo-
tions.2–4 Certainly, ectopic eruption is a wide category
dontia, peg-shaped teeth, severe rotations and bad
of any type of anomaly in which the teeth present an
positioning of adjacent teeth, retention of deciduous
abnormal eruption pathway. Thus, tooth transposition
teeth, dilacerations, and malformations of other
should be considered a subdivision of ectopic erup-
teeth.4–8 The anomaly affects both dental arches of
tion, being the extreme condition in this category.
both males and females but is more frequent among
A clear and objective definition of tooth transposition
females and in the maxillary arch.6,9–11 Interestingly, si-
multaneous occurrence of transposition in both arches
a
Professor, Bauru Dental School, USP; professional, Ortho- is seldom observed, even in the deciduous dentition.4,5
dontic Sector of the Hospital for Rehabilitation of Craniofacial
A possible explanation for tooth transposition would
Anomalies, USP; Professor of Post Graduation, Orthodontics,
Araçatuba Dental School—UNESP, Araçatuba, Brazil. be an exchange in position between developing tooth
b
Graduate PhD student in Orthodontics, Araçatuba Dental buds.2,12,13 Because of the high incidence of retained
School—UNESP, Araçatuba, Brazil. deciduous canines associated with tooth transposition,
c
Graduate PhD student in Orthodontics, Araçatuba Dental some authors report deciduous teeth as being the pri-
School—UNESP; Temporary Professor, Department of Dentist-
mary etiologic factor of this anomaly.11–14 In addition,
ry, Health Sciences School, UNB, Brasilia, Brazil.
d
Chairman Professor of the Discipline of Preventive Ortho- the intraosseous migration of the canine,15 trauma to
dontics, Department of Child and Community Dentistry at Ara- the deciduous tooth,16 and the presence of cysts and
çatuba Dental School—UNESP; Professor of Post Graduation pathologies17 also have been suggested. However, the
in Orthodontics at Araçatuba Dental School—UNESP, Araça- present data strongly attribute this disturbance to ge-
tuba, Brazil.
netic influences within a multifactorial inheritance mod-
Corresponding author: Dr Mauricio de Almeida Cardoso,
UNESP-Araçatuba, Orthodontics, Araçatuba, São Paulo 16015– el.5,18–20
050 Brazil (e-mail: maucardoso@uol.com.br). Peck and Peck21 conducted a wide review of case
Accepted: February 2006. Submitted: January 2006. reports of tooth transpositions in the maxillary arch and
䊚 2006 by The EH Angle Education and Research Foundation, established a classification based on anatomical fac-
Inc. tors. From 201 case reports reviewed, the authors

DOI: 10.2319/012906-32 167 Angle Orthodontist, Vol 77, No 1, 2007

168 CAPELOZZA FILHO, ALMEIDA CARDOSO, AN, BERTOZ

Figure 1. Initial extraoral (a, b) and intraoral (c–g) photographs showing Class I facial pattern, Class I molar relationship, and transposition of
maxillary right canine and first premolar, both at initial stage of eruption.

found the following conditions of transposition, in de-
creasing order of frequency: (1) canine–first premolar,
(2) canine–lateral incisor, (3) canine on the site of first
molar, (4) lateral incisor–central incisor, and (5) canine
on the site of central incisor.
This study presents a case report of clinical man-
agement of unilateral tooth transposition of a maxil-
lary right canine and first premolar. The first scientific
reference on transposition of maxillary canine and
premolar is probably credited to Miel,1 who described
in detail a case with bilateral transposition in 1817
and suggested the genetic involvement of this anom-
aly.
Transposition of the maxillary canine and first pre-
molar presents a low prevalence in the population, be-
ing found in 0.03% of Swedish schoolchildren,22 0.13%
of Arabian dental patients,23 0.25% of Scottish ortho-
dontic patients,24 and 0.51% of individuals in a com-
posite African sample.25
Following a multifactor hereditary model, Peck et al5
suggested that transposition of a maxillary canine and
first premolar is genetically controlled. This conclusion
was reached because of the moderate rate of bilateral
occurrence, gender-related differences, increased
prevalence of additional dental anomalies as hypodon-
tia, occurrence following a hereditary pattern, and
varying prevalence among populations.
When there is transposition of canine and first pre-
molar, the canine is usually displaced in mesiobuccal
direction between the first and second premolars, and

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TREATMENT OF UNILATERAL TRANSPOSITION
Figure 2. Initial lateral cephalogram (a) exhibiting normal character-
istics, initial panoramic radiograph (b) demonstrating the magnitude
of transposition, and periapical radiographs of maxillary and man-
dibular incisors (c, d) at treatment onset.
the first premolar is frequently distally tipped and dis-
placed in a mesiopalatal direction. Moreover, the de-
ciduous canine is often present, yielding a temporary
space restriction.18
Early diagnosis of a developing transposition is ex-
tremely important and has a great influence on prog-
nosis. This may usually be performed by a conven-
tional panoramic radiographic examination when the
169
patient is between 6 and 8 years of age. When the
alteration is detected early, interceptive procedures in-
cluding extraction of deciduous teeth and placement
of eruption guides for the permanent teeth may be per-
formed, thus preventing complete development of the
anomaly. On the other hand, when transposition is de-
tected at a later stage, orthodontic planning must ad-
dress the indications for against extraction and the se-
quence of correcting tooth positioning.
There are more therapeutic options for the maxillary
arch compared with the mandibular arch because of
the increased potential for orthodontic management in
the maxilla. From an esthetic and functional perspec-
tive, it is preferable to move the affected tooth into its
normal position in the dental arch, especially if trans-
position affects only the coronal portion of the tooth.
In this condition, uprighting and correction of rotation
of the affected tooth are commonly required, provided
there is enough available space for normal alignment
of these teeth.
When transposition is more severe and affects the
crown and root, the attempt to reposition affected
teeth in the dental arch is complicated and may cause
damage to the supporting tissues. Thus, alignment of
these teeth in their transposed positions is usually
required. The decision to extract a permanent tooth,
usually the premolar, is more attractive when teeth
affected by transposition present caries or poor peri-
odontal support or when there is a severe tooth-size
discrepancy.
When the practitioner decides to reposition the
transposed teeth, as in some recent case reports26–28
and the present one, care should be taken during me-
chanical management to avoid occlusal interference
and root resorption, as well as bone loss, especially
of the buccal bone plate. Thus, the palatally displaced
premolar should be initially moved to allow free
movement of canine on the buccal aspect to its nor-
mal position. After repositioning of the canine, the
premolar may be corrected. The disadvantage of this
approach is the time required for correction, which
will be compensated by the esthetic and functional
outcome.4
CASE REPORT
A girl aged 9 years and 3 months (Figures 1 and 2)
presented with the chief complaint of transposition of
the maxillary right canine and first premolar. She pre-
sented a Class I pattern29 with good facial relation-
ships, a slightly convex profile, a mixed dentition with
a mild Class II malocclusion, and moderate deviation
of the maxillary midline. The cephalometric character-
istics were normal without clinically significant skeletal
deviations. Clinically, the canine was positioned on the
Angle Orthodontist, Vol 77, No 1, 2007
170 CAPELOZZA FILHO, ALMEIDA CARDOSO, AN, BERTOZ

Figure 3. Intraoral photographs showing archwire segmentation. The utilization of two wires allowed palatal movement of the premolar with
simultaneous mesial movement of canine.

Figure 6. Follow-up periapical radiographs at the 13th month. Note

the superimposition of the maxillary right canine over the root of the
maxillary right first premolar.

Figure 4. Ninth month of treatment. Note the wire extension on the

mesial aspect of the maxillary right canine (b) to allow its mesial
displacement.

Figure 5. Photographs at the 13th month. The anterior teeth were included in the mechanics, and an open coil was placed for simultaneous
distal movement of first premolar and mesial movement of lateral incisor for midline correction.

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TREATMENT OF UNILATERAL TRANSPOSITION 171

Figure 7. At the 15th month, the maxillary right canine was included in the mechanics with a superimposed archwire and inset bend, which
was gradually released to allow extrusion.

Figure 8. Midline correction and progressive lingual and buccal movement of maxillary right canine and first premolar, respectively, were
performed at the 20th month of treatment.

buccal aspect in relation to the first premolar. A pan-

Figure 9. Follow-up periapical radiographs of maxillary incisors at
the 20th month reveal acceptable biological cost in relation to the
orthodontic treatment time.
oramic radiographic examination revealed that trans-
position affected the crown and root.
An individualized treatment plan utilizing segmented
mechanics was proposed to reposition the ectopic
tooth into its normal position with a reserved prognosis
and need of reevaluation.
Treatment was initiated by banding of permanent
maxillary first molars with a triple tube on the buccal
aspect and a lingual tube for placement of a remov-
able transpalatal arch. Anchorage was achieved by
utilization of a passive transpalatal arch and asym-
metric cervical headgear used at nighttime to favor
correction of the maxillary midline.

Figure 10. Final photographs with correction of transposition of maxillary right canine and first premolar. Hyperplasia was observed at
the maxillary anterior region after 26 months of partial orthodontic mechanics, which encouraged shortening of the remaining treatment
time.

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172
Figure 11. The final radiographs show the correction of the trans-
position, with correct position of canine and first premolar roots. Also,
an anomalous conical single root in tooth 47 was observed (b).
After 3 months, a standard edgewise bracket was
bonded on the palatal aspect of the maxillary right
first premolar (Figure 3) and a segmented 0.019- ⫻
0.025-inch titanium molybdenum alloy (TMA) wire
was fabricated with first- and third-order bends for
achievement of root movement of the maxillary right
Angle Orthodontist, Vol 77, No 1, 2007
CAPELOZZA FILHO, ALMEIDA CARDOSO, AN, BERTOZ
first premolar in a palatal direction. The aim of this
cantilever was to displace the first premolar outside
the alveolar ridge in a palatal direction for achieve-
ment of space to allow mesial movement of the ca-
nine. This movement was performed with the aid of
a passive segment of 0.019- ⫻ 0.025-inch rectangu-
lar wire and an open coil between the canine and first
molar.
At 9 months, the maxillary right second premolar
was included in the mechanics (Figure 4) and an
open coil was adapted between the maxillary right
second premolar and canine for achievement of me-
sial movement of the canine. The wire segment on
the palatal aspect was kept to retain the maxillary
right first premolar during this movement and to re-
duce the risk of contact between the roots of the
transposed teeth.
At 11 months, a bracket was bonded on the buccal
aspect of the maxillary right first premolar, and distal
movement of this tooth was initiated with placement of
an open coil between the maxillary right lateral incisor
and first premolar. The standard edgewise bracket
bonded on the buccal aspect allowed easier torque
control during progressive buccal movement of the
palatally displaced first premolar. At this stage, the coil
used to move the canine was kept inactive.
At 13 months, the anchorage units were removed
and the maxillary right central and lateral incisors and
maxillary left central and lateral incisors and canines
were included in orthodontic mechanics (Figures 5 and
6). At this stage, a stainless steel 0.016-inch wire with
an inset bend at the region of the maxillary right first
premolar was placed for tooth alignment, partially
keeping the palatal position of the maxillary right first
premolar. The open coil between the maxillary right
first premolar and lateral incisor was kept to promote
simultaneous distal movement of the maxillary right
first premolar and mesial movement of the maxillary
right lateral incisor, with a consequent midline correc-
tion. Mesial movement of the maxillary right canine
was continued.
At 15 months, it was possible to perform mechanics
with a superimposed archwire on the maxillary right
canine (Figure 7) for achievement of progressive lin-
gual and buccal movement of the maxillary right ca-
nine and first premolar, respectively (Figures 8 and 9).
At 26 months, during finalization, it was decided not to
perform orthodontic treatment on the mandibular arch
because of the favorable occlusal relationship
achieved (Figure 10). Also an anomalous conical sin-
gle root in tooth 47 was observed (11). The treatment
objectives and strategic sequence adopted may be
better understood by referring to the drawings (a–d)
presented in Figure 12.
TREATMENT OF UNILATERAL TRANSPOSITION 173

Figure 12. The drawings (a) and (b) display the objective to displace the maxillary right first premolar (crown and root), achieving alveolar
space for mesial movement of the maxillary right canine. Afterward, the maxillary right first premolar was moved in distal and palatal direction
(c), whereas the maxillary right canine was moved in mesial direction, revealing the difficult treatment of tooth transposition. Finally, the corrected
transposition is presented (d), only with need of final positioning of the maxillary right canine, with torque control.

CONCLUSION
Segmented mechanics was adopted to allow better
control of individualized movement of the target teeth,
reducing the adverse effects of continuous archwires
for correction of transposition. Treatment planning with
repositioning of the transposed teeth was selected be-
cause of the patient’s chronological and dental ages
and the absence of a tooth-size discrepancy in the
maxillary arch. The total treatment time of 26 months
was relatively long yet acceptable considering the ab-
solute correction of the alteration. At treatment com-
pletion, the patient presented gingival alterations prob-
ably related to the utilization of fixed appliances (Fig-
ure 13).
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